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All HCAs should complete care certificate, says Cavendish review

All healthcare assistants should complete a certificate in “fundamental” care before they can look after patients unsupervised, a government commissioned review has recommended.

Introducing the Certificate of Fundamental Care would help drive up standards and improve the status of support workers, according to the independent review into support worker training and support.

The review, which was carried out by the Sunday Times journalist Camilla Cavendish, said HCAs who completed the certificate should be allowed to use the term “nursing assistant” in a bid to reduce the number of current job titles held by support workers.

It said the “profusion of job titles” for support workers in health and social care must be reduced to improve public understanding of the different nursing roles.

During her research for the review, Ms Cavendish found 60 different job titles to describe similar roles across health and social care.

She found HCAs in many places were carrying out procedures such as cannulation, giving injections, female catherisation and applying complex dressings

Ms Cavendish said the description of the work of HCAs as “basic care” understated the skill needed for many of the tasks and proposed the Certificate of Fundamental Care would be a “badge of honour” and “a first step in a caring career”.

“I have come away from this project thinking that our society is incredibly lucky to have so many people with a dedication to caring,” she wrote.

“But I also fear that if we continue to take them for granted, if we do not fix dysfunctional systems of commissioning and regulation, we may find as we grow old that they are not there to look after us.”

Ms Cavendish proposed the certificate be the same across health and social care, allowing the development of a “shared set of language and values”, while a higher certificate or certificates should also be introduced to allow more opportunity for career progression.

She called for the Care Quality Commission to require support workers in all settings to have achieved the certificate before they can work unsupervised.

Ms Cavendish, who has written extensively about health, was asked to examine the role of HCAs and social care support workers in the wake of the Francis report into care failings at Mid Staffordshire Foundation Trust.

Ms Cavendish also recommends that directors of nursing take back responsibility for the HCA workforce from human resources departments.

She echoed proposals announced by Health Education England recently to make it easier for HCAs to progress into nursing by recognising caring experience.

However, she noted many HCAs had no ambition to become nurses, after seeing how much time they spend on paperwork.

The review’s terms of reference did not include the heavily debated issue of mandatory regulation for HCAs, which led to unions criticising the review when it was initially announced.

Royal College of Nursing chief executive and general secretary Peter Carter welcomed proposals for the certificate and “moves to bring the professions closer”.

However, he warned without statutory regulation of support workers, there was nothing to stop “unsuitable” HCAs from moving between providers.

Unison head of health Christine McAnea described the review as a “once in a generation” opportunity to make changes and called on the government to commit to properly fund training for HCAs.

The government will respond fully to the review when it publishes its full response to the Francis report later this year.

The Nursing and Midwifery Council said it welcomed the report’s “emphasis on the valuable” work HCAs do.

“In the interests of public protection, the NMC welcomes the proposal for a mandatory certificate of fundamental care and a requirement that all HCAs have this to work with patients. 

“It will assist nurses in assuring themselves that they are delegating appropriately,” an NMC spokeswoman said.

Crystal Oldman, chief executive of the Queen’s Nursing Institute, said: “A certificate of fundamental care would provide a minimum agreed level of education and training and would arguably be beneficial in raising care standards generally, but we need to go further to protect the public and introduce a system of national regulation.

“This is particularly the case in the community, where care takes place behind closed doors, without the direct supervision of the qualified nurse who is ultimately responsible for the work of the healthcare support worker.”

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Readers' comments (39)

  • If they are doing skilled jobs and are to be trained could we call for them to be paid as a band 4 perhaps?

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  • michael stone

    I heard snatches of camilla discussing this on radio 4 this morning, but I was doing something in a different room and cannot be sure that I 'heard it all straight'.

    I think I heard Camilla suggesting that when HCAs are being trained to do certain tasks, they should be trained ALONGSIDE nurses who are being trained for the same task: if she did say that, I can see how it looks sensible from one perspective, but it isn't obvious to me how that could be achieved in practice ?

    I seem to remember that she wants HCAs who work in hospitals to have a different title (I think 'nursing assistant' or 'assistant nurse' was what she mentioned) but that HCAs who work outside of hospital in the community, would not have the same title as those who work in hospitals - encouragingly, her views on the title issue, were shaped by having actually asked HCAs for their opinions about it.

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  • I thought all HCA's were meant to have NVQ level 2 or be registered to do it within 6 months of employment, as part of the Care Act 2000.
    This has not been enforced. What is the point of any more pronouncements if the regulators do not inspect or regulate. The CQC is again proving that it is not fit for purpose.
    Also Dr Carter the HCA's are not a profession. They are an occupation. The definition of a profession is a group who self regulate and have a body of knowledge.

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  • Some interesting comments!
    Unfortunately it demonstrates how the NHS has become fragmented in its approach to "a national service" by having so many different titles and the expectations within those roles. The public need clear guidance/information around the roles of individuals who look after them.
    the comment around NVQ's is valid, however I have seen over the years a "dilution" in the expectations of the awards
    and question some of the subjects covered.
    I believe that CQC do need to be more rigorous in the auditing process and perhaps this will come about following their review
    In the field of learning disabilities there was a unique qualification for HCA's (LDQ formerly LDAF) and an expectation that staff had this or were prepared to work towards it. (now gone)
    We need to to get back the fundamentals! Communication, values and attitudes a case also for graduate nurses

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  • Anonymous | 10-Jul-2013 9:48 am

    I'd have no problem with them being paid a Band 4. They deserve a decent remuneration for their hard work. However, they should not be seen as a cheap replacement for registered nurses and that is already happening. Also, RNs should be paid much more to reflect their training and level of responsibility and accountability.


    Anonymous | 10-Jul-2013 11:28 am

    Whilst I agree to a point that the fragmentation of the NHS (to which I am bitterly opposed) has played a part in "having so many different titles and the expectations within those roles.", I do think that the increasing complexity within healthcare is also a significant issue. Nurses and their team colleagues now work in many more varied environments and specialties than in the past. Our roles have changed and developed, which is great....but the pay and conditions remain basic and insulting. (As is the attitude of the government to this profession, but we seem to accept that.)

    We always talk about going back to basics, and again, I agree to a point.

    I trained in the early 1980s and did my degree much later. I had worked for six months as a care assistant prior to the commencement of my training, like the vast majority of my fellow students. The universities which supply our current student nurses have always made care experience a condition of acceptance for those who apply for nurse training, (to go out and gain experience prior to starting their course, if they haven't done so already). Now it is being bandied about by the government like it's a new idea. HCAs where I worked in the 1990s and afterwards were trained to NVQ Level II. These are not new ideas. Camilla Cavendish is saying NOTHING new that has not been said for years by Nurses! It is staggering (and a reason to really look at ourselves), if what we say is ignored until a journalist for the Times says it.

    It also just proves that, if you wait long enough, what you were doing years ago will come back into fashion......but only after years of underinvestment and the emergence of all the disasters we nurses predicted were going to happen (and didn't shout loudly enough to prevent).

    Whilst not wishing to get mired into the graduate nurse/old school debate, I work with a terrific bunch of nurses of all ages, training and experience. I see no difference in the communication, values and attitudes amongst the non-graduate and graduate staff.

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  • I am a HCA working in general practice.
    I have worked as an HCA for 30 years in nursing homes, hospital and now in general practice. I have an abundance of work experience and have gained NVQ level 3 as well as certificates in ECG module, Wound Care, Ear Syringing, Influenza & Pneumococcal and Vit B 12 injections, I have a foundation in Spirometry, Phlebotomy and various other certificates. I am always willing to learn and am looking for more training. I cannot complete my nurses training due to family commitments, but if ever the chance came up to do on the job training I would jump at the chance. There was talk at one point about senior healthcare assistant becoming the old state registered nurse. I would happily pay to become state registered for all the hard work I do. The pay increase would also be welcome. I love my job as it stands. I couldn't think of doing anything else,other than nursing, to me it is my vocation. as far as I can see i'm totally dedicated, even more than some trained nurses.

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  • Well, Well, Well, have we not just been waiting for this moment to come round?
    I know what we can do, it's simple .................BRING BACK THE ENROLLED NURSE...............problem soved. They will have both training and regulation, and get paid a decent wage for doing the job.

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  • Anonymous | 10-Jul-2013 3:21 pm

    But you remain not a registered nurse and do not have their level of responsibilty and accountability. It is about more than how hard you perceive you are working and how much money you think you should be paid in comparison to your registered colleagues.

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  • Are ASBO's not called a 'Badge of Honour'?

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  • I totally agree about bringing back the state enrolled nurse,I trained as this in 1983 and I feel that compared to now,you had more time by the patients bedside giving full total care than nowadays where I feel more time is spent on the computer and less time with the patient,

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  • Train up HCAs, bring back enrolled nurses and you will only find that THEY will spend more time on the computer!

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  • tinkerbell

    let's re-invent the wheel that hasn't been tweeked for some time. All my old clothes have now come back in fashion.
    If you wait long enough someone will try to re-introduce something as a new idea until some of us old timers spoil it all by saying didn't we do that years ago, what spoil sports - just when they thought they could pass it off a new, innovative, transformational idea. Party poopers!

    Did I hear mention an article on NT about having a 'badge of honour' or did I imagine that. It is getting harder and harder to differentiate between la la land and reality lately.

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  • Train all HCA's up to a minimum such as NVQ2/3 And pay them appropriately And bring back Enrolled Nurses And bring back hospital based training as another option, not to replace university training but as another option...

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  • .....and they too can sit at computers, tick boxes, do all the paperwork and all the other stuff that they accuse RNs of doing all day, because they WILL have replaced university trained nurses.

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  • ....and they will cost less.

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  • its funny how all these comments fall into a bickering mess, all we want as HCA's is the appropriate levels of acknowledgement for the work we put in , I work in a highly specialised area and have done for the past nine years , I love my job and the people i work with are amazing , all the RN's I work with actively encourage me , I cannulate, venepuncture and lead in decontamination, our roles have changed over the years, so maybe camilla should also look at the boys and girls that work in these areas too

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  • paul williams | 11-Jul-2013 11:28 am

    It's funny how comments which are legitimate and are making important points whether using sarcasm, humour, etc., are classified as bickering.
    Take the points being made and think about them. You may not agree with the viewpoint, but don't dismiss them as a bickering mess. They are no more but no less valid than yours.

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  • Completely agree that the Nvq Programme was an excellent fundamental care programme for HCA's but as other have said it went out of fashion. Having led NVQ programmes for a very large Acute Trust they were good fundamental programmes but cannot be compared to any of the old SEN training. I believe we need to move forward with a programme for HCA's that reflects the needs of the curret care provision and provide recognition for the excellent work they do within their role.

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  • There is the basic important care such as washing dressing, toileting, feeding which nurses and carers should not be exempt from. However, as nurses have more responsibility, then the basic care should mainly be the responsibility of the carer. They should be taught to be assertive and if the work load is too much, then they should ask the nurse for help.
    There are other things carers do due to more training that is: ECG, venepunture, dressings etc. They have then taken on futher responsibitity if they agree to take on additional jobs( that is not instead of jobs).
    More responsibility should mean better pay and these carers must be assertive to ensure they do.
    No one is forced to take on extra responsibilities unless they are bullied into it.
    My advice to carers is ensure you are paid for your responsibilities.

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  • whats the definition of 'unsupervised' I thought all HCA's worked under the direction of an RN. After all the RN is accountable for thier own practice and tha tof HCA's working with them.

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